provincial diabetes inpatient management initiative ... · insulin therapy (bbit) insulin pump...
TRANSCRIPT
P R O V I N C I A L D I A B E T E SI N P A T I E N T M A N A G E M E N T I N I T I A T I V EI M P R O V E D G L Y C E M I C M A N A G E M E N TI N H O S P I T A L
1 in 5 adult patients admitted to hospital in Alberta hasdiabetes. When compared to their non-diabetic counterparts,patients with diabetes have longer hospital stays.
D I A B E T E SO B E S I T Y &N U T R I T I O NS T R A T E G I C
C L I N I C A LN E T W O R K
( D O N S C N )
The DON SCN is leading a provincial initiative with the
goal of improving and standardizing how patients with
diabetes are cared for in Alberta’s hospitals.
This is a multipronged quality improvement initiative, in
collaboration with AHS provincial Pharmacy, AHS
provincial Nutrition and Food Services, and the Zone
operational areas.
It involves a multidisciplinary approach to diabetes
management, with the patient and family as key team
members.
P R O J E C T B U L L E T I N - F A L L 2 0 1 6
BACKGROUND
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I N T H I S I S S U EU P D A T E S F O R
B a s a l B o l u sI n s u l i n T h e r a p y( B B I T )
I n s u l i n P u m pT h e r a p y ( I P T )
D i a b e t i cK e t o a c i d o s i s( D K A )
R e d u c i n g I n s u l i nE r r o r s
I n p a t i e n tG l y c e m i cM a n a g e m e n t
P o i n t o f C a r eT e s t i n g
P g s .2 - 4
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P g .4
P g .5
P g .5
P g .5
WWW .AHS .CA /DONSCN
N u t r i t i o n a n dF o o d S e r v i c e s
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Hyperglycemia (high blood sugar) increases the risk of complications including: post-operative infections,pneumonia, diabetic ketoacidosis (DKA), and delays wound healing.
Literature suggests that patients with diabetes experience hyperglycemiaover 1/3 of the time when theyare in hospital. Alberta data is consistent with this figure; with hyperglycemia experienced approximately36% of the time blood sugars are tested.
Improving blood sugar control in hospital has been associated with shorter length of stay in hospital anddecreased rates of readmission.
EVIDENCE
For more information visit the Canadian Diabetes Association (CDA) Clinical Practice Guidelines (CPGs) for InHospital Management of Diabetes @ http://guidelines.diabetes.ca/Browse/Chapter16
National Guidelines recommend blood glucose targets of 5-10 mmol/L for patientswith diabetes in hospital .
IMPLEMENTATION AND SUSTAINABIL ITY OF BASAL BOLUS INSULINTHERAPY (BBIT ) AND IMPROVED GLYCEMIC MANAGEMENT
BBIT i s a way o f o rde r i ng mu l t i p l e da i l y i n j ec t i ons o f subcu taneous( sc ) i n su l i n t ha t be t t e r r ep l i ca tes how ou r body na tu ra l l y p roducesi nsu l i n .
BB IT i s a p roac t i ve app roach t ha t a l l ows c l i n i c i ans t o cus tom izei nsu l i n r eg imens based on t he un i que i nsu l i n needs o f each pa t i en t .I t a l so m in im i zes t he f l u c t ua t i ons i n b l ood g l ucose l eve l s , r educesep i sodes o f bo th hype rg l y cem ia and hypog l ycem ia , and suppo r t skeep ing a pa t i en t ’ s b l ood suga rs w i t h i n t he t a rge t r ange o f 5 10mmo l / L . BB IT has been shown t o be an e f f ec t i ve way t o managepa t i en t s ’ d i abe tes du r i ng t he i r hosp i t a l s t ay , and i s s im i l a r t o howmany pa t i en t s manage t he i r d i abe tes i n t he commun i t y .
Sliding Scale Insulin (SSI) continues to be commonly used in the treatment of diabetes within theinpatient setting. Unfortunately, the use of the “sliding scale” regime treats hyperglycemia after it hasoccurred. It is not individualized to the patient and can result in large blood glucose fluctuationthroughout the day. These fluctuations make the patient feel unwell, and increase morbidity, mortality andlength of stay. SSI does not align with current practice guideline recommendations.
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Graphic by Stephen WebsterRN , Uni t 61 , FMC
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AUDIT DATA TO SUPPORT THE UPTAKE AND SUSTAINABIL ITY OF BASAL BOLUSINSULIN THERAPY AT EARLY ADOPTER SITES
An aud i t t oo l , cons i s t i ng o f seve ra l i nd i ca to r s , hasbeen c rea ted t o suppo r t ea r l y adop te r s i t e s i n t heup take and sus ta i nab i l i t y o f t he c l i n i ca l p rac t i cechange t o basa l bo l us i n su l i n t he rapy .
Shown r i gh t i s a samp le o f a f ew o f t he i nd i ca to r spopu la t ed i n Tab leau f o r f r on t l i ne c l i n i c i ans t oaccess and u t i l i z e w i t h t he i r t eams .
BBIT (CONT 'D )
EARLY ADOPTER SITES
Canmore Hospi ta l and Oi l f ie lds Hospi ta l in Black Diamond(2 ru ra l s i tes in Calgary Zone ) were the f i r s t ear l y adopters i tes , both implement ing at the beg inn ing of th i s year .
Chinook Regiona l Hospi ta l , inLethbr idge implemented BBIT andimproved glycemic managementacross the i r s i te in Apr i l 2016 .
All 3 hospitals have identified PHYSICIAN, NURSING, PHARMACY AND ADMINISTRATIVE champions to workcollaboratively to support the implementation of this clinical practice change. Each site is currentlycollecting data that will populate an audit tool in Tableau, so the teams can see the outcomes of theirpractice changes.
The above 3 early adopter sites will also be providing feedback on the provincial BBIT order set and theaccompanying blood glucose record. These 2 forms will then be revised (if necessary), and made availablefor provincial ordering at the end of September.
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PARTNERING WITH CALGARY ZONE HOSPITAL IST PROGRAM
Every day in Calgary, the Hospitalists care for over 800 patients in the hospital. These clinicians haveexpressed an interest in glycemic optimization. The multidisciplinary site champions, connected to theHospitalist program, across four sites in Calgary came together for a Train the Trainer (TTT) day on April8th, 2016 at the South Health Campus auditorium. The site specific teams have been busy over the past fewmonths educating their peers and collaborating on their implementation strategies.
The DON SCN provincial team is excited to be working with and supporting the Calgary Zone Hospitalistgroup in their Glycemic Optimization initiative.
Multidisciplinary champions from hospitals within theCalgary Zone gathered to learn more about the
reimplementation of basal bolus
Dr. Karmon Helmle (Endocrinologist) andKelly Mrklas (Knowledge Translation Scientist)discuss solutions to identified barriers to the
implementation of this clinical practice change
Learn ing Together ! Calgary c l in ic ianslearn how to enter BBIT orders in to
Sunr i se Cl in ica l Manager
BUILDING OTHER PARTNERSHIPSBBIT (CONT 'D )
EDMONTON ZONE E -SIMULATION
We a re p l eased t o be wo rk i ng w i t h AHSES imu la t i on t o exp l o re oppo r t un i t i e s f o r t hemu l t i d i s c i p l i na r y t eam t o use s imu la t i on t o suppo r tchanges i n p rac t i ce t ha t w i l l imp rove g l y cem icmanagemen t f o r pa t i en t s i n hosp i t a l s w i t h d i abe tes .
The DON p rov i nc i a l t eam has connec ted w i t hbo th t he Covenan t and AHS s i t es i n Edmon tonZone , and i s l ook i ng f o rwa rd t o co l l abo ra t i ngto imp rove g l y cem ic managemen t a t t he i rr espec t i ve s i t es .
The p rov i nc i a l d i abe tes i npa t i en t managemen t t eam has pa r t ne red w i t h t he CoACTin i t i a t i ve t o be a l i gned a t t he un i t l e ve l . The re a re many CoACT e l emen t s t ha tsuppo r t t he imp lemen ta t i on o f
imp roved g l y cem ic managemen t . Ou r two t eams a re now f o rma l i z i ng t he i n t e r sec t i ons o f ou r i n i t i a t i ves , sothese can be sha red w i t h new ope ra t i ona l t eams cons i de r i ng t he imp lemen ta t i on o f BB IT and imp rovedg l ycem ic managemen t . Bo th i n i t i a t i ves a l so f ocus on a mu l t i d i s c i p l i na r y app roach t o ca re , w i t h t he pa t i en tas a key membe r o f t he mu l t i d i s c i p l i na r y t eam, i n t he cen t r e o f t he p l ann ing o f t he ca re be i ng p rov i ded .
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SAFE MANAGEMENT OF INSULIN PUMPTHERAPY IN HOSPITAL
The safe management of insulin pump therapy(IPT) in hospitals is another aspect of the DONSCN provincial diabetes inpatient managementinitiative. The focus of this initiative over thecoming year will be on implementation of newprovincial guidelines at all hospitals in Albertacaring for patients that manage their diabetes withan insulin pump.
To introduce the new guidelines, forms anddirections for selfmanagement of IPT in hospital,a webinar was hosted on April 28 2016 by Dr. JulieMcKeen (Endocrinologist in Calgary Zone andPhysician Lead on the provincial diabetesinpatient management initiative) and IsabelleEmery (Patient Advisor, DON SCN).
SAFE MANAGEMENT OF DIABETICKETOACIDOSIS (DKA) IN THEEMERGENCY DEPARTMENT
DiabeticKeto
Acidosis
The Emergency SCN, along with the Chief MedicalInformation Office, have created a comprehensivedocument for the Safe Management of (Adult) DKAin Alberta Emergency departments.
This is a provincial Clinical Knowledge Topiccreated as part of the collaborative initiativebetween AHS Clinical Knowledge & ContentManagement (CKCM) and the Strategic ClinicalNetworks™ (SCN).
This initiative aims to develop provincial clinicalguidance and practice standards to be enabled bythe future AHS Provincial Clinical InformationSystem solution.
For AHS employees; the DKA document can be foundon the Clinical Knowledge & Content Management(CKCM) Service webpage on Insite, under KnowledgeTopics.
The recording of thewebinar can be accessedby clicking here.
Click here to accessthe guidelines.
SIMPLIFIED FORMULARY AND PATIENT SPECIFIC DELIVERY OF INSULIN IN HOSPITAL
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Provincial pharmacy is leading two quality improvement initiatives:(i) Simplified Insulin Formulary and (ii) Patient Specific delivery ofInsulin.
Both initiatives will support reducing errors associated with the use ofinsulin consistently one of the top 3 causes of medication errors inhospitals.
Over the past year AHS Pharmacy has supported all the AHS hospitals intheir transition to the new formulary. They have also supported most sites intheir implementation of patient specific delivery, primarily the transition todisposable insulin pens.
PROVINCIAL (ADULT) INPATIENT GLYCEMIC MANAGEMENT POLICY AND PROTOCOLSFOR HYPO AND HYPERGLYCEMIA MANAGEMENT
A provincial multidisciplinary working group, with representation from AHS and Covenant, across 5 Zones,has been meeting biweekly since March 2016 to create provincial documents that will support improvedglycemic management in hospital. The glycemic management policy aligns with national standards, andoutlines strategies for supporting patients to achieve their glycemic targets.
The protocols for hypo and hyperglycemia management aim to support staff in early recognition andtreatment, to prevent negative outcomes for patients. Thank you to the working group for their time andinvaluable input.
The documents that have been created to date will be sent for consultation with numerousstakeholders in the Fall, before being put forward to the AHS Executive Leadership Team for approval.
POLICYCOLLABORATING WITH PROVINCIAL LAB POINT OF CARE TESTING (POCT) NETWORK
The provincial inpatient management team is pleased to be collaborating with the provincial POCTNetwork on a number of fronts. The POCT Network has oversight of the glucose meters used in allhospitals across Alberta.
Currently a pilot is being conducted at Chinook Regional Hospital, in which additional alerts are addedonto their glucometers. The alerts are set at 3.9mmol/L to support early treatment of a patient withhypoglycemia, and at 18.1mmol/L to support early intervention for a patient with hyperglycemia.
These alerts are in addition to the alerts that are currently present on all glucometers to alert providerswhen the patient’s blood sugar is critically high or critically low.
The additional alerts are aligned with the provincial BBIT order set, and also with the provincial policyand accompanying protocols for hypo and hyperglycemia management that are being developed.
The pilot at Chinook Regional Hospital in Lethbridge will inform the addition of alerts at otherhospitals throughout the province.
AHS sta f f can f ind more in format ion on InS i te , by search ing Diabetes Management .
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Nutrition and Food Services (NFS) has participated in the Provincial InPatient Diabetes Management Initiative of the DON SCN since itsinitiation. Primarily, NFS has been focused on improving the patient’s ability to properly control their diabetes by ensuring appropriatemenus and menu choices for patients or residents with diabetes. This has involved a multipronged approach based on the bestevidence and a survey of adult inpatients with diabetes carried out by the DON SCN in summer 2014 that indicated the followingthemes related to diet:
IMPROVING FOOD AND NUTRITIONAL INFORMATION FOR PATIENTS MANAGINGTHEIR DIABETES IN HOSPITAL
Some patients wanted carbohydrate information to help them manage their diet.Many patients EXPECTED sugar free foods and no juice.Patients didn't agree that a regular diet that is well planned can meet the needsof those with diabetes ... they believed that they needed a "special" diet e.g.sugar free foods.
NFS currently has menus tailored for patients with diabetes. Steps have been taken toaddress the issues identified resulting in changes to patient menus at hospitals acrossthe province.
Juice has been removed as a standard item for all patients with diabetes, although it canbe chosen if a patient wishes it or is eating poorly. Diet yogurt and diet pudding choices will become available for patients in the fall of 2016.
The main focus has been to provide carbohydrate information to patients who have the knowledge and ability to count their “availablecarbohydrate” and match it to their insulin. Different tools have been developed for sites without and with computerized menu systems asfollows:
For sites without computerized Menu Software (mainly smaller sites), a paper based document titled, “Carbohydrate Content ofFoods Served in Hospital”, was developed. It indicates the available carbohydrate values of menu items in the portion sizes served inthe hospital. This document will shortly be added to InSite as a link from the Nutrition & Food Services Education page, as well aslinked as a resource on DON SCN webpage.
For sites with computerized menu software (mainly larger sites), providing available carbohydrate values as information on themenus was not as easy as expected. There were limitations of the software itself and the menu documents provided to patientslacked sufficient space. But with some adaptations, it was determined that available carbohydrate for most menu items could beadded to the menus that patients receive to choose their food and on the tray tickets provided with the meals. Implementation of theuse of available carbohydrate on tray tickets will occur shortly in a staggered fashion for Calgary Zone. Evaluation of the tools isplanned for 2017.
For more information, contact Janet Nielsen, RD, Program Lead, Standards and Practice, Nutrition Services at [email protected].
For more information about the DON SCN provincial diabetes inpatient management initiative;
please contact us at:
Content provided by Glenda Moore, Manager, DON SCN and Project Lead for the Diabetes
Inpatient Management Initiative.
Most sweet or baked desserts will not be provided to patients with diabetes. For example, orange citrus cake and angel food cake withstrawberry compote were removed as standard choices on the menu for dessert. Artificial sweeteners, diet jams and diet syrup continue to be available.
Submitted by Janet Nielsen , RDProgram Lead , Standards and Practice , Nutrition Services